Failure to Address Uncontrolled Pain and Withdrawal in Non-Verbal Resident
Penalty
Summary
The facility failed to identify and address uncontrolled pain and withdrawal symptoms in a resident who could no longer reliably swallow oral medications. The resident, who had severe cognitive impairment, dementia, and generalized muscle weakness, was admitted with chronic pain due to osteopenia and had a care plan in place for pain management. Despite this, documentation showed repeated instances where the resident refused or was unable to take prescribed medications, including pain medications, due to difficulty swallowing and refusal to open their mouth. Nursing staff attempted to administer medications by crushing them and mixing them with food, but the resident only accepted a few bites before refusing further. Progress notes indicated that the resident's pain medications, as well as other essential medications for anxiety, depression, and muscle weakness, were frequently not administered over a period of time. Observations revealed the resident exhibited non-verbal signs of pain, such as facial grimacing, groaning, rigid posturing, and restless legs, which were audible and visible to staff. Despite these clear indications of discomfort and withdrawal, there was no evidence that the facility had a protocol for assessing pain in non-verbal residents, nor was there timely communication with the nurse practitioner regarding the resident's inability to take oral medications. Interviews with staff confirmed that the resident's non-verbal pain was significant and that the nurse practitioner was unaware of the ongoing medication administration issues until informed by the surveyor. The director of nursing acknowledged discussions about comfort care but stated that no changes had been made to the resident's medication regimen due to issues with the power of attorney. The lack of timely intervention and communication resulted in the resident experiencing unmanaged pain and withdrawal symptoms.